JCAH survival guidelines for 1983.

Abstract

A survey conducted by the Joint Commission on the Accreditation of Hospitals (JCAH), an event most ED managers do not enjoy, may not be as difficult as expected. As with other management responsibilities, an organized and systematic approach to planning and preparation will enable you to appear cool and calm during the actual accreditation process and come out “smelling like a rose.” JCAH surveyors do not tend to search for areas of noncompliance in an effort to deny accreditation to a hospital, but instead they attempt to assess the quality of patient care in each department. To determine the level of care provided in an emergency department, one must objectively evaluate the department in relation to predetermined standards of care. A nurse manager who is responsible for an emergency department that routinely and consistently provides quality care, has a professional staff, and meets the patients’ needs will not receive a poor rating from JCAH if a few simple guidelines are followed. A better understanding of the accreditation process will help to allay fears and allow time to be spent preparing rather than worrying. The accreditation survey of the JCAH is a totally voluntary process whereby the hosptial administration submits an application requesting the survey. Once the application is processed and fees are remitted, advance notice of approximately 4 weeks will be provided prior to the site visit. JCAH states that its mission is to improve the quality of care and services provided in organized health care settings through a voluntary accreditation process, and it is dedicated to promoting quality care in hospitals. To promote quality care, the JCAH accreditation survey assesses the extent of a hospital’s compliance with applicable standards. At least one of the following modes of assessment is included: statements from authorized hospital personnel, hospital documentation of compliance, answers to questions concerning implementation of a standard and examples of its implementation, and on-site observations. The on-site survey of most hospitals is completed in 1 to 4 days, depending on bed capacity, and is accomplished by JCAH surveyors. The survey team, usually consisting of four or five individuals, views the institution in terms of physical plant, storage, safety, equipment, policies, procedures, quality assurance (QA) programs, medical records, and overall quality of care. In the past, accreditations have extended for a varying number of years, but a new policy provides for only a 3-year period of accreditation. The ED manager is responsible for assuring compliance with JCAH standards for emergency services and guiding the department through the accreditation process. Probably the most important aspect in preparing for the survey is to become thoroughly familiar with JCAH standards, specifically those pertinent to the emergency department. This is best accomplished by utilizing the current (1983) edition of the Accreditation Manualfor Hospitals. The text contains all standards for emergency services, as well as general policies. Once you know the JCAH requirements, it is time to develop an organized plan of action and to facilitate staff awareness of the upcoming survey and the criteria against which your department will be judged. Involving the nursing staff not only provides help with necessary tasks but also allows a better understanding of the accreditation process, thereby promoting professional and personal growth and a feeling of self-worth. Some hospital administrators prefer to utilize a consulting group to survey their hospital prior to the JCAH survey. This provides identification of areas